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transcript
Quality Assurance / Quality Assurance Performance
Improvement & Monitoring For The Health Information
Management/Record Department
February 12, 2014 (Bakersfield, CA)
February 13, 2014 (San Jose, CA)
February 14, 2014 (Riverside, CA)
OBJECTIVES
Participants will identify the key management principles for: Managing the HIM/Record Department Assuring a HIM/Record Department Evaluation is
followed up
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OBJECTIVES -2
Participants will: Identify those QA processes that are used as a
guiding principal for managing the facility Specifically review the QA process as it relates to
managing audits Develop a plan for your own audit process and
follow up action plan Will identify the ADM, MRD and HIM/Record
Consultant action/follow up
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QA PROCESS
Review of the QA Process Identify areas of concern/continuous quality
improvement processes, set out the goals, identify the criteria, collect data, identify measurement, evaluate and assess the information, analyze the causative factors, develop action plans and follow up – recycle!!
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QA
Responsible for the overall direction of the facility’s quality improvement functions through a quality assessment/improvement program/plan
Will spend more time on this in future workshops
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QUICK MANUAL REVIEW
Let’s look at the manual Table of ContentsKey focus areas today
QA audits and monitoring Audit tools HIM Dept Evaluation (H.O. #1)
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HIM / RECORD DEPARTMENT ORGANIZATION
Review of the HIM/Record Department organization and expectations
HIM/Record Department Evaluation (H.O. #1)1. Location of Items in the HIM/Record Dept.
2. The Basics of organization
3. Auditing and monitoring policy/schedule/organization/follow-up – QA reports
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ORGANIZATION OF HIM / RECORD DEPT.
Review the Organization of the HIM/Record Dept (refer to HIM #4005)
Identify those Health Information Department items for improvement and documentation items from the HIM/Record Consultant
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ORGANIZATION OF HIM / RECORD DEPT. -2
PRACTICE Determine for your facility those areas that need
improvement. List them from your knowledge. Reconcile for all the facilities
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TOP 20 DEFICIENCIES & FOCUSED AUDITS
Top 20 Deficiencies (H.O. #2) #1 Quality of Care – Identify those audits
that would measure documentation, i.e., behavior drugs, falls, restraints, pain, etc.
#2 Care Plans – Identify where the most deficiency is applicable to your facility; at C of Condition, after IT Team Quarterly Reviews with the MDS resulting in update of CP
#3 Pharmacy Procedures – results from the new pharmacy survey, RECAPS, med/tx. Documentation, etc.
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TOP 20 DEFICIENCIES & FOCUSED AUDITS -2
Measure against Unnecessary Drugs – Pharmacy QI include in QA process (refer to HIM #7050 Behavior Drugs Monitors Antipsychotic (H.O. #3.1) Non-Antipsychotic (H.O. #3.2)
Complete Records – Discharge Summary to be reviewed later
Note: Reference only – cover during audit discussion
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WHY PLAN FOR AUDITS AS PART OF QA?
In order to ensure that the documentation of the quality of care and services provided to all residents meets the needs of the residents and reflects high quality outcome of services and care process
Documentation supports those services and we can document the quality of services.
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QA PROCESS
Identifies and addresses quality issues; including documentation items.
Provides a tool to coordinates the qualitative documentation activities of all departments.
Establishes assessment and improvement priorities for audits and follow up.
Sets expected outcomes for documentation o0f resident care, services and related administrative services;
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QA AUDITS AND MONITORING
REVIEW of the Medical Records Compliance Audit – this is the “standard” (H.O. #4)
Let’s agree on a standard. (Get input from the facilities).
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QA - PLANNING
Identify those standard audits that need to be carried out
Identify the LifeHouse priorities – the rating of where LifeHouse stands against those CMS identified areas where improvement is needed
Determine which audits will apply to your facility
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COLLECT INFORMATION
Establish the Medical Record Director’s schedule for auditing
Standard Audits – those are the required audits as set by LifeHouse
Review and determine agreement on the Medical Records Compliance Audit (H.O. #4)
Determine the required without exception – identify those audits/monitoring
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ADMISSION MONITOR
Let’s walk the Admit audit process Admission Monitor (H.O. #5.1) Admission 7-14-21-30 Day Combined Monitor
(H.O. #5.2) Admission JCAHO Subacute Monitor (H.O. #5.3)
Note: We may change to a Discharge from Medicare and at discharge
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ADMISSION MONITOR -2
PRACTICE Discussion Q&A from last 5 admit audits Identify out of the 3 audit items best meet your
needs and AHIS will reconcile
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DAILY QUALITY ASSURANCE REVIEW SYSTEM – CHANGE OF CONDITION
Used to identify problems, concerns and conditions where additional follow up, review or referral are needed or desired
A method of continuous quality care outcome review
Action/results oriented
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SYSTEM BENEFITS
Reduces duplication of efforts Follow up tasks identified and assigned to staff on
specified due datesFocus on
Timely identification of deficiencies/problems Prevention of repeat deficiencies/problems Continued review of follow through until resolution
so that nothing “falls through the cracks”
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SYSTEM BENEFITS -2
Utilizes time spent in daily stand up meeting to maximize results – quality outcomes
Promotes ID team involvement in problem identification and problem solving
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SYSTEM COMPONENTS
24 hour report/shift report Incident reportsChange of condition monitorReports of resident/family
concerns/complaintsDaily quality assurance review form (log)Daily standup meeting
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24 HOUR REPORT
Centralizes nursing communications on a shift by shift basis
Helps to ensure timely follow up from shift to shift or day to day
Usually the first documented indication of a new or impending problem or change of condition
An important link in the audit trail Important source of information for the IDT as
well as nursing 24
INCIDENT REPORTS
Another important link in the audit trail
Provides detailed information that must be carefully documented, reviewed and trended
Must be integrated into the QA process ongoing
Daily review of reports to ensure quality outcomes and timely follow up 25
CHANGE OF CONDITION MONITOR
Reviews information given in the 24 hour report, incident reports and telephone orders
Identifies changes and problems requiring follow up in the last 24 hours (or 72 hrs. over the weekend)
Centralizes and identifies changes and any deficiencies or “loose ends” in documentation
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RESIDENT/FAMILY CONCERNS AND COMPLAINTS
Frequently not picked up and processed in a methodical manner
An important source of information about the resident, impending or actual problems and changes of condition
Need to be identified and addressed by the IDT in a timely manner
IDT involvement and reporting is critical
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CHANGE OF CONDITION MONITOR -2
Complete daily prior to the standup meetingReview 24 hour report, incident reports and
telephone orders that denote a change of condition
List all changes of condition on the monitor form
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WHAT MAY INDICATE A CHANGE OF CONDITION?
Changes can be physical, mental or psychosocial
Change can Be slow to develop and show
subtle signs or Develop rapidly with more obvious
signs and symptoms
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WHAT MAY INDICATE A CHANGE OF CONDITION? -2
When reviewing the 24 hr. report look for Reports to nursing by family, C.N.A.’S, R.N.A.’S,
ancillary services that something has occurred or is changing in the resident’s condition
Don’t overlook resident/family complaints
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WHAT MAY INDICATE A CHANGE OF CONDITION? -3
New orders for: An antibiotic Treatment Physical or chemical restraint New support or assistive device Weight loss or gain X-rays and labs
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WHAT MAY INDICATE A CHANGE OF CONDITION? -4
Changes in orders can also indicate a change of condition. For example: Increase in dose of psychotropic medication A change from one type of physical restraint to
another type A change in type of assistive device used to treat a
condition or maintain mobility Change in treatment order because the site is not
responding
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WHAT MAY INDICATE A CHANGE OF CONDITION? -5
When reviewing incident reports look for: Falls Medication errors Injuries/death resulting from defective equipment Resident to resident or resident to staff altercations
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COMPLETING THE COC MONITOR
Look at the audit form (H.O. #6) – reference HIM #7050
Review the Legend at the bottom of the form These are the codes used to complete the form
Review the Incidents and Accidents box These are some general related guidelines
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COMPLETING THE COC MONITOR -2
PRACTICE Review of the last 3 change of condition monitors
from each facility in your group Summarize issues Plan for facility and Corporate-wide
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STANDARD AUDITS
Change of Condition – dailyWeekly skin report (done by the treatment
nurse and audited by the MRD for qualitative documentation). (HIM/Record Consultant may need to assist with the quality training.)
Quantitative Reviews – Is it or isn’t it there?Clinical Record Monitor (reference HIM
#7050)
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STANDARD AUDITS -2
Weight audit – (may be done by others)Admission AuditDischarge AuditsPsychotherapeutic drugsSpecialized monitoring, i.e., review H.O. #4
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AUDITS AND THE FOLLOW UP
Audit schedule with required audits and QA reporting and schedule
Audit/Monitor Schedule on the Administrator’s and DNS desk; follow up to assure MRD audits carried out as planned.
HIM/Record Consultants assists with above and provides training and monitoring to assist with the quality of the process 38
MEDICAL RECORDS AUDIT SCHEDULE
H.O. #7Monitored by HIM/Record Consultant
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DISCHARGE SUMMARY REQUIREMENTS
Review HIM Policies/Procedures Discharge Chart Monitor (HIM #3520) Order of Filing – Shortened Discharge Chart (HIM
#3506) Inhouse Order of Filing (HIM #4035)
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GENERAL DOCUMENTATION REQUIREMENTS
Willful Omission and Willful Falsification of Records….”AVOID THE RISKS”
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OBJECTIVES
Participants will Identify the correct method to document, timely,
accurately Identify what is willful falsification and willful
omission Recognize documentation correction issues
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GENERAL DOCUMENTATION GUIDELINES
Every entry is recorded promptly after the care/tx is given, i.e., for medications/treatments the documentation is done at the time of the med/tx
Food intake, at the end of the meal Intake and output – at the time of measure of
the intake and the output
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ENTRIES
Complete, concise, accurate!! Made by the person carrying out the care/tx
(not by another person for someone else) Chronological
Used abbreviations only if approved by the facility and in the manuals
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ENTRIES -2
In black or dark blue ink or typewritten – e-record
Must be capable of being copiedMust be legibleHighlighters may cause obliteration
when copied – recommend against use Include date, month, year and time (if
appl.)Signed by appropriate person with
professional title, i.e., C.N.A., R.N., L.V.N.
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EXERCISES
Are there situations when documentation is carried out late?
A fellow staff member tells you they observed Mrs. Jones (the fellow staff members resident) sitting and falling to one side and she wasn’t sure what was wrong but informed the nurse. Please document that in the record. What should be done?
When documenting is it necessary to include position title, i.e., C.N.A., R.N., L.V.N., etc.?
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DO NOT!!
Use white out, write over an entry,black out an entry
Sign for another person Copy records or completing any portion of a
record without your personal knowledge the care was given, the data is accurate. Otherwise this could be construed as “falsification of records”
Leave blank spaces Document before an entry occurs
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EXERCISES
Falsification of records may be interpreted in the following situations.1. White out is used and then someone wrote over the white out. Is this allowed for legal documentation?
2. It is o.k. to leave a blank line between your note and the last note written?
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EXERCISES
Now that we have computer documentation, order entry in your situation – and the med/tx records are printed there is no way to have a record that is incomplete or not accurate? What could be a question??
If you do not have time you can leave the space for charting until the next day. Is that correct?
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CORRECTION Records may be corrected by drawing
one line through the error, designate error, initial the error and chart the correct information with date and time if applicable.
Computer system – each system has a method of correcting the documentation and ability to track. Follow the guide.
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WILLFUL FALSIFICATION
Entries in the record shall be factual Accurately reflect the services provided to the
resident Accurately reflect the condition of the
resident, Accurately reflect the resident’s response to
treatment and services
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ALERT TO ACCURATE CHARTING
All staff shall be aware that an entry in the record that is made with the knowledge that the record falsely reflected the condition or situation is “willful material falsification”
Subject to civil penalty and $$…personally can be assigned to the employee
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WILLFUL OMISSION
If staff are aware of any untoward event that affects the resident, and not documenting that information correctly, therefore causes the record to falsely reflect the condition of the resident, or the care or services provided shall be considered to be a “willful material omission”
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EXERCISE
A staff member observed the resident and found the resident on the floor. The person did not know what happened, however documented that the resident had sat down on the floor and did not seem to be in any distress. The resident was complaining of pain. The fact was that the resident was found on the floor, the resident was complaining of pain and this was reported to the nurse, but did not include a note. Is this willful falsification or willful omission?
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WHAT TO DO ABOUT AUDITS!!
Correction or late entries are possible but care needs to be taken between falsification and accurate correction.
Practice Examples: Q & A
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AHIS CONTACTS
Elizabeth Rumbin, RHIT, HI Consultant
smrumbin@aol.com or 805-895-4517
Khaleelah Wagner, RHIA, HI Consultant
khaleelahwagner@hotmail.com or 909-717-7102
Staci LePage, RHIT, HI Consultant
stacilepage@comcast.net or 916-202-5797
Rhonda Anderson, RHIA, President
rhonda@ahis.net or 714-299-0573
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